Implementation Evaluation of a Complex Intervention to Improve Timeliness of Care for Veterans with Transient Ischemic Attack

T M Damush, E J Miech, N A Rattray, B Homoya, Lauren S Penney, A Cheatham, S Baird, J Myers, C Austin, L J Myers, A J Perkins, Y Zhang, B Giacherio, M Kumar, L D Murphy, J J Sico, D M Bravata, T M Damush, E J Miech, N A Rattray, B Homoya, Lauren S Penney, A Cheatham, S Baird, J Myers, C Austin, L J Myers, A J Perkins, Y Zhang, B Giacherio, M Kumar, L D Murphy, J J Sico, D M Bravata

Abstract

Background: The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program was designed to address systemic barriers to providing timely guideline-concordant care for patients with transient ischemic attack (TIA).

Objective: We evaluated an implementation bundle used to promote local adaptation and adoption of a multi-component, complex quality improvement (QI) intervention to improve the quality of TIA care Bravata et al. (BMC Neurology 19:294, 2019).

Design: A stepped-wedge implementation trial with six geographically diverse sites.

Participants: The six facility QI teams were multi-disciplinary, clinical staff.

Interventions: PREVENT employed a bundle of key implementation strategies: team activation; external facilitation; and a community of practice. This strategy bundle had direct ties to four constructs from the Consolidated Framework for Implementation Research (CFIR): Champions, Reflecting & Evaluating, Planning, and Goals & Feedback.

Main measures: Using a mixed-methods approach guided by the CFIR and data matrix analyses, we evaluated the degree to which implementation success and clinical improvement were associated with implementation strategies. The primary outcomes were the number of completed implementation activities, the level of team organization and > 15 points improvement in the Without Fail Rate (WFR) over 1 year.

Key results: Facility QI teams actively engaged in the implementation strategies with high utilization. Facilities with the greatest implementation success were those with central champions whose teams engaged in planning and goal setting, and regularly reflected upon their quality data and evaluated their progress against their QI plan. The strong presence of effective champions acted as a pre-condition for the strong presence of Reflecting & Evaluating, Goals & Feedback, and Planning (rather than the other way around), helping to explain how champions at the +2 level influenced ongoing implementation.

Conclusions: The CFIR-guided bundle of implementation strategies facilitated the local implementation of the PREVENT QI program and was associated with clinical improvement in the national VA healthcare system.

Trial registration: clinicaltrials.gov: NCT02769338.

Keywords: quality of care; implementation science; implementation strategy; audit and feedback; CFIR; transient ischemic attack; mixed methods.

Conflict of interest statement

The authors declare that they have no competing interests. TD, AP, LM: Disclosed funding from a VA HSRD QUERI grant. DMB, EJM, NR, LP, BH, JM, AJC, SB, CA, JJS, ZY, LDM, BG, and MK reported no conflicts of interest.

Figures

Figure 1
Figure 1
Implementation activities over the 1-year active implementation period.

References

    1. Bravata D, Myers L, Arling G, Miech EJ, Damush T, et al. Quality of care for Veterans with transient ischemic attack and minor stroke. JAMA Neurology. 2018;75(4):419–427. doi: 10.1001/jamaneurol.2017.4648.
    1. Johnston KC, Connors AF, Wagner DP, Knaus WA, Wang XQ, Haley EC. A predictive risk model for outcomes of ischemic stroke. Stroke; a journal of cerebral circulation. 2000;31:448–455. doi: 10.1161/01.STR.31.2.448.
    1. Johnston S. Short-term prognosis after a TIA: a simple score predicts risk. Cleveland Clinic Journal of Medicine. 2007;74(10):729–736. doi: 10.3949/ccjm.74.10.729.
    1. Rothwell P, Johnston S. Transient ischemic attacks: stratifying risk. Stroke; a journal of cerebral circulation. 2006;37(2):320–322. doi: 10.1161/01.STR.0000200555.89117.d2.
    1. Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke; a journal of cerebral circulation. 2014;45(7):2160–2236. doi: 10.1161/STR.0000000000000024.
    1. Lavallée P, Meseguer E, Abboud H, et al. A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurol. 2007;6(11):953–960. doi: 10.1016/S1474-4422(07)70248-X.
    1. Luengo-Fernandez R, Gray A, Rothwell P. Effect of urgent treatment for transient ischaemic attack and minor stroke on disability and hospital costs (EXPRESS study): a prospective population-based sequential comparison. Lancet Neurol. 2009;8(3):235–243. doi: 10.1016/S1474-4422(09)70019-5.
    1. Giles M, Rothwell P. Risk of stroke early after transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol. 2007;6(12):1063–1072. doi: 10.1016/S1474-4422(07)70274-0.
    1. O'Brien EC, Zhao X, Fonarow GC, et al. Quality of Care and Ischemic Stroke Risk After Hospitalization for Transient Ischemic Attack: Findings From Get With The Guidelines-Stroke. Circulation Cardiovascular quality and outcomes. 2015;8(6 Suppl 3):S117–124. doi: 10.1161/CIRCOUTCOMES.115.002048.
    1. Bravata DM, Myers LJ, Arling G, Miech EJ, Damush T, Sico JJ, Phipps MS, Zillich A, Yu Z, Reeves M, Williams LS, Johanning J, Chaturvedi S, Baye F, Ofner S, Austin C, Ferguson J, Graham GD, Rhude R, Kessler CS, Higgins DS, Jr, Cheng E. Quality of care for Veterans with transient ischemic attack and minor stroke. JAMA Neurology. 2018;75(4):419–427. doi: 10.1001/jamaneurol.2017.4648.
    1. Damush TM, Miech EJ, Sico JJ, et al. Barriers and facilitators to provide quality TIA care in the Veterans Healthcare Administration. Neurology. 2017;89(24):2422–2430. doi: 10.1212/WNL.0000000000004739.
    1. Homoya BJ, Damush TM, Sico JJ, et al. Uncertainty as a Key Influence in the Decision To Admit Patients with Transient Ischemic Attack. Journal of general internal medicine. 2018.
    1. Bravata DM, Myers L, Homoya B, Miech EJ, Rattray N, Perkins A, Zhang Y, Ferguson J, Myers J, Cheatham A, Murphy L, Giacherio B, Kumar M, Cheng E, Levine D, Sico J, Ward M, Damush T. The protocol-guided rapid evaluation of veterans experiencing new transient neurological symptoms (PREVENT) quality improvement program: rationale and methods. BMC Neurology. 2019;19:294. doi: 10.1186/s12883-019-1517-x.
    1. Williams L, Daggett V, Slaven JE, Yu Z, Sager D, Myers J, Plue L, Woodward-Hagg H, Damush TM. A cluster-randomised quality improvement study to improve two inpatient stroke quality indicators. BMJ Qual Saf. 2016;25(4):257–64. doi: 10.1136/bmjqs-2015-004188.
    1. Harvey G, Kitson A. PARIHS revisited: from heuristic to integrated framework for the successful implementation of knowledge into practice. Implementation Science. 2016;11:33. doi: 10.1186/s13012-016-0398-2.
    1. Damschroder LJ, Lowery JC. Evaluation of a large-scale weight management program using the consolidated framework for implementation research (CFIR) Implementation Science. 2013;8(1):51. doi: 10.1186/1748-5908-8-51.
    1. Rattray NA, Damush TM, Luckhurst C, Bauer-Martinez CJ, Homoya BJ, Miech EJ. Prime movers: Advanced practice professionals in the role of stroke coordinator. J Am Assoc Nurse Pract. 2017;29(7):392–402. doi: 10.1002/2327-6924.12462.
    1. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Science. 2009;4(1):50. doi: 10.1186/1748-5908-4-50.
    1. Bosworth H, Olsen M, Grubber J, et al. Two self-management interventions to improve hypertension control: a randomized trial. Annals of internal medicine. 2009;151(10):687–695. doi: 10.7326/0000605-200911170-00148.
    1. Bosworth H, Powers B, Olsen M, et al. Home blood pressure management and improved blood pressure control: results from a randomized controlled trial. Archives of internal medicine. 2011;171(13):1173–1180. doi: 10.1001/archinternmed.2011.276.
    1. Ranta A, Dovey S, Weatherall M, O'Dea D, Gommans J, Tilyard M. Cluster randomized controlled trial of TIA electronic decision support in primary care. Neurology. 2015;84(15):1545–1551. doi: 10.1212/WNL.0000000000001472.
    1. Rothwell P, Giles M, Chandratheva A, et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet (London, England) 2007;370(9596):1432–1442. doi: 10.1016/S0140-6736(07)61448-2.
    1. Powell B, Powell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, Proctor EK, Kirchner JE. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci. 2015;10:21. doi: 10.1186/s13012-015-0209-1.
    1. Bidassie B, Williams LS, Woodward-Hagg H, Matthias MS, Damush TM. Key components of external facilitation in an acute stroke quality improvement collaborative in the VHA. Imp Sci. 2015;10:69.
    1. Ritchie MJ, Kirchner JE, Townsend JC, Pitcock JA, Dollar Km, Liu C-F. Time and Organizational Cost for Facilitating Implementation of Primary Care Mental Health Integration. JGIM; 2019; 10.1007/s11606-019-05537-y.
    1. Cruess RL, Cruess SR, Steinhert Y. Medicine as a Community of Practice: Implications for medical education. Acad Med. 2018;93(2):185–191. doi: 10.1097/ACM.0000000000001826.
    1. Kizer KW, Dudley RA. Extreme makeover: Transformation of the veterans health care system. Annual review of public health. 2009;30:313–339. doi: 10.1146/annurev.publhealth.29.020907.090940.
    1. Hagg H, Workman-Germann J, Flanagan M, et al. Implementation of Systems Redesign: Approaches to Spread and Sustain Adoption. Agency for Healthcare Research and Quality: Rockville, MD (USA); 2008.
    1. Li J, Zhang Y, Myers LJ, Bravata DM. Power Calculation in Stepped-Wedge Cluster Randomized Trial with Reduced Intervention Sustainability Effect. Journal of Biopharmaceutical Statistics. 2019;29(4):663–674. doi: 10.1080/10543406.2019.1633658.
    1. Mdege ND, Man MS, Taylor Nee Brown CA, Torgerson DJ. Systematic review of stepped wedge cluster randomized trials shows that design is particularly used to evaluate interventions during routine implementation. J Clin Epidemiol. 2011;64(9):936–948. doi: 10.1016/j.jclinepi.2010.12.003.
    1. Hamilton A, Brunner J, Cain C, et al. Engaging multilevel stakeholders in an implementation trial of evidence-based quality improvement in VA women’s health primary care. TBM. 2017;7(3):478–485.
    1. NVivo qualitative data analysis software; QSR International Pty Ltd. Version 12, 2018.
    1. Miech E. The GO. A New Context-Sensitive Instrument to Measure Group Organization Level for Providing and Improving Care. Washington DC: Score; 2015.
    1. Averill JB. Matrix analysis as a complementary analytic strategy in qualitative inquiry. Qualitative health research. 2002;12(6):855–866. doi: 10.1177/104973230201200611.
    1. Creswell JW, Klassen AC, Clark VLP, Smith KC. Best Practices for Mixed Methods Research in the Health Sciences. Washington, DC, USA: Office of Behavioral and Social Sciences Research 2011. .
    1. Averill JB. Matrix analysis as a complementary analytic strategy in qualitative inquiry. Qualitative health research. 2002;12(6):855–866. doi: 10.1177/104973230201200611.
    1. Miech EJ, Rattray NA, Flanagan ME, Damschroder L, Schmid AA, Damush TM. (2018). Inside Help: An Integrative Review of Champions in Healthcare-Related Implementation. SAGE Open Medicine. 6: 2050312118773261.
    1. Flanagan ME, Plue L, Miller KK, Schmid AA, Myers L, Graham G, Miech EJ, Williams LS, Damush TM. A qualitative study of clinical champions in context: Clinical champions across three levels of acute care. SAGE Open Medicine, 2018;6.
    1. Kirk MA, Kelley C, Yankey N, Birken SA, Abadie B, Damschroder L. A systematic review of the use of the Consolidated Framework for Implementation Research (CFIR) Implementation Science. 2016;11:72. doi: 10.1186/s13012-016-0437-z.
    1. Proctor EK, Powell BJ, McMillen JC. Implementation strategies: recommendation for specifying and reporting. Imp Sci. 2013;8:139.
    1. Waltz TJ, Powell BJ, Fernandez ME, Abadie B, Damschroder LJ. Choosing implementation strategies to address contextual barriers: diversity in recommendations and future directions. Implementation Science. 2019;14:42. doi: 10.1186/s13012-019-0892-4.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe